U N I V E R S I T Y
UND
O F
N O R T H
D A K O T A
PSYCHOLOGICAL SERVICES CENTER
210 MONTGOMERY HALL
290 CENTENNIAL DRIVE STOP 7108
GRAND FORKS, NORTH DAKOTA 58202-7108
701.777.3691
SLIDING FEE SCHEDULE
Effective 4/30/14
Therapy (Individual/Group) rate: 5$ per session for UND students and staff and their families. For all
others, fee is assessed by income and the number of people reliant on it:
ANNUAL GROSS
INCOME*
NUMBER OF PERSONS IN HOUSEHOLD**
1
2
3 or more
$0 – 20,000
$7.00
$6.00
$5.00
$20,001 – 30,000
$10.00
$9.00
$8.00
$30,001 – 40,000
$12.00
$10.00
$9.00
$40,001 – 50,000
$14.00
$12.00
$10.00
$50,001 – 60,000
$17.00
$15.00
$12.00
$60,001 – 70,000
$20.00
$18.00
$16.00
$70,001 and over
$25.00
$22.00
$20.00
* Gross Income = total earned from salary/wage earners (income tax included) and net profits from businesses e.g., farming.
** Refers to the number of persons depending on the household income. Not roommates (i.e., college).
Applied Behavior Analysis. Charges are listed in dollars per hour; Estimated cost per year, assuming 20
hours per week for 50 weeks, appear in parentheses.
COMBINED ANNUAL
HOUSEHOLD INCOME
NUMBER OF DEPENDENTS
1
2
3+
Less than $20,000
.40 (400)
.20 (200)
.02 (20)
$20,000-$39,999
.60 (600)
.40 (400)
.20 (200)
$40,000-$59,999
.80 (800)
.60 (600)
.40 (400)
$60,000-$99,999
1.20 (1200)
1.00 (1000)
.80 (800)
$100,000-$149,999
2.00 (2000)
1.80 (1800)
1.60 (1600)
$150,000-$249,999
4.00 (4000)
3.80 (3800)
3.60 (3600)
More than $250,000
8.00 (8000)
8.00 (8000)
8.00 (8000)
Assessment rate: Assessment (includes Interviewing, Test Administration, Scoring, Report Writing &
Feedback); Assessment services are billed at a base rate of $225 for an 8 hour block of testing. Additional
testing will be billed at a rate of $10/hour in addition to test fees for a maximum fee of $300.
PAYMENT EXPECTATIONS: Fees for services are required at the time of the appointment. For
therapy, clients will be charged a $10.00 intake fee. All payments will receive receipts for their paid fees.
For assessments, at least 1/2 of the total fee must be paid before testing can begin. We do not bill insurance
companies; however, these statements can be used to submit to your insurance claims department. Should
the situation arise that a client is financially unable to afford the fee (e.g., loss of job), this concern should
be raised with your therapist who will inform the Clinic Director.
Please Note: Appointment changes must be made 24 hours prior to appointment time. Late cancellations or
no shows are assessed the regular session fee.
CLIENT AGREEMENT: Based on the above schedule, I understand that I will be expected to pay:
$_______ for individual/group therapy at the time of service, or $_______ per hour for ABA
$_______ for assessment services prior to the first assessment session
I acknowledge that these fees have been explained to me by the clinic associate, and that I agree to pay for
the services as outlined in this document. If in the future my ability to pay for services changes, I will
inform my therapist.
If I show up for services and am unable to pay for services based upon this agreement, I services will not be
refused, but this will need to be discussed with my therapist, and directed to the Clinic Associate or Clinic
Director for further review. In this circumstance, referral to other resources may be warranted, if minimal
payments are not possible.
DATE: _________
CLIENT NAME: ___________________________ CLIENT#: _________
Signature of Client
Date
Reason For Review
Signature of Assessor/GSC
$ Approved
PSC Director Signature
Signature of Client